Registered Nurses’ Association of Ontario (RNAO)

158 Pearl Street, Toronto, ON M5H1L3 Ph. 416 599 1925 Toll-free 1 800 268 7199 Fax 416 599 1926 RNAO.ca

Registered Nurses’ Association of Ontario (RNAO) Feedback on revised Standards for Public Health Programs and Services Written Submission to the Ministry of Health and Long-Term Care May 5, 2017

RNAO feedback on modernization of the Ontario Public Health Standards May 5, 2017 2

Introduction The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses (RN), nurse practitioners (NP), and nursing students in all roles and sectors across Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses' contributions to shaping the health system, and influenced decisions that affect nurses and the public they serve. RNAO appreciates the opportunity to provide feedback to the Ministry of Health and Long-Term Care (MOHLTC), Population and Public Health Division, on the Standards for Public Health Programs and Services Consultation Document.1 This submission has been informed by our expert members working in public health through the Community Health Nurses' Initiatives Group (CHNIG), public health nurses working specifically to advance health equity through action on the social determinants of health, and ongoing research to support population health and health equity by RNAO staff. RNAO appreciates the importance of modernizing the Ontario Public Health Standards (OPHS) since its last iteration in 2008 in order to advance the province's Patients First Strategy.2 RNAO has been actively engaged in providing evidence-informed solutions to health system transformation3 4 5 6 to support the "structural changes that are necessary to achieve an improved, integrated, and efficient health system in Ontario that moves to one that is more person centred."7 Improving Population Health and Decreasing Health Inequities Through the Ontario Public Health Standards The overarching goal of public health programs and services is "to improve and protect the health and well-being of the population of Ontario and reduce health inequities."8 RNAO endorses this goal as it is consistent with international,9 10 11 national,12 13 14 and provincial15 16 17 18 evidence-informed public policy and is congruent with RNAO's organizational values.19 Organizational standards, including the 2008 version of the Ontario Public Health Standards, have been identified as one of ten promising practices to reduce social inequities in health at the local public health level.20 OPHS 2008 has been recognized as providing "a theoretical framework to address health inequities" as well as a "mechanism by which local public health can work to reduce them."21 RNAO appreciates the opportunity that the MOHLTC is taking to build on content that supports health equity in the 2008 OPHS22 through the 2017 OPHS revision process. In particular, the MOHLTC is to be commended for strengthening opportunities to address health inequities by embedding it into all public health work through the introduction of a new Health Equity Foundational Standard.


A substantive concern that RNAO has with draft 2017 OPHS is that the critical goal of improving population health and decreasing health inequities is undermined by a lack of coherence in the policy framework for public health programs and services (figure 2, p. 5). There is a well-established body of literature on population health,23 24 25social determinants of health,26 27 social determinants of health inequities,28 29 and opportunities for public health to reduce health inequities30 31 32 that contradicts this policy framework's focus on healthy behaviours as a domain/objective. If the actual intention is to focus on upstream approaches33 to decrease health inequities then it is logically inconsistent to spotlight healthy behaviours framed as choices made by individuals. Too often attributing "poor choices" to knowledge deficits, moral failings, or lack of personal responsibility leads to blaming people who are already marginalized. This is not helpful for people who experience discrimination attributed to behaviour, limits the reduction of health inequities and may even make some health inequities worse.34 35 Evidence overwhelmingly shows that a lifestyle approach in the absence of robust upstream social determinants of health policy does not lead to health equity and/or improved outcomes in population health. "Lifestyle drift" has been described as the "tendency to recognize the need to act on the more structural determinants of health inequalities but to instead develop interventions targeting the more behavioural determinants of health."36 OPHS language of "upstream efforts" (p. 3) but operationalizing behavioral health fits perfectly with the metaphor of policy that starts by "recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors."37 RNAO urges that instead of exacerbating lifestyle drift in the OPHS, the MOHLTC must utilize the World Health Organization's conceptual framework on the social determinants of health (as intermediary determinants of health) and social determinants of health inequities (or the structural determinants of health inequities). Appendix 1 of this document includes figures and references for this conceptual framework, a framework for tackling social determinants of health inequities, a priority public health conditions analytic framework, and an application of priority public health conditions analytic framework to alcohol-attributable harm. Alcohol was chosen as a timely example since the province currently has a "healthy behaviours" approach with a focus on Canada's Low-Risk Alcohol Drinking Guidelines and encouragement to "drink responsibly."38 While these measures might assist some individuals, the bigger threat to population health and health equity is the province's expansion of the physical availability of alcohol and lack of a public health evidence-informed provincial alcohol strategy.39 Just as there is an expectation that current theory and evidence will inform public health practice for safe water, rabies control, and reduced transmission of tuberculosis, so too must the OPHS use the same rigorous approach to advance population and health equity. Lessons can be learned from the NHS Health Scotland's analysis of


epidemiological data to address the question: "what would it take to eradicate health inequalities?" Evidence that all-cause socio-economic inequalities in mortality persist despite reductions for some specific causes, and that inequalities are greater with increasing preventability, suggest that focusing on reducing individual risk and increasing individual assets will ultimately be fruitless in reducing inequalities and may even increase them. Elimination and prevention of inequalities in all-cause mortality will only be achieved if the underlying differences in income, wealth and power across society are reduced.40 RNAO Feedback, Questions, and Recommendations RNAO's specific feedback, questions and recommendations linked to the draft 2017 OPHS document have been organized below in a table format.

OPHS Document RNAO Feedback, Questions, and Recommendations Figure 1: What is Public Health?

Population health approach circle

shown in Figure 1 shows four

segments: population health

assessment; social determinants

of health; healthy behaviours;

and healthy communities. Text

for healthy behaviours reads:

"supporting people to make the

healthiest choices possible." p. 3

Please see previous substantive feedback on the imperative to

incorporate current theories and evidence as current framing works

against population health and health equity goal.

According to the Ontario's Public Health Sector Strategic Plan,

"public health is the organized efforts of society to prevent illness,

disease and injury through a sustained combination of approaches,

including one-on-one health services, health promotion, health

protection and healthy public policies."41

Or, as the Public Health

Agency of Canada defines public health: "an organized activity of

society to promote, protect, improve, and when necessary, restore the

health of individuals, specified groups, or the entire population. It is a

combination of sciences, skills, and values that function through

collective societal activities and involve programs, services, and

institutions aimed at protecting and improving the health of all

people."42

These definitions are helpful in their recognition of public health as a

societal activity with opportunities to impact the health outcomes of

individuals, families, groups, and population. The later definition is

helpful in recognition of "sciences, skills, and values."

Figure 2: Policy Framework

Domains and objectives for

social determinants of health and

healthy behaviours p. 4-5

Please see previous substantive feedback on the imperative to

incorporate current theories and evidence as current framing works

against population health and health equity goal.

The explicit focus on assessing health status that extends beyond

traditional health indicators to social factors and beyond traditional

morbidity/disease to mental and social well-being is welcome.

Public health transformation is

triggered by a series of drivers.

p. 6

RNAO asks that our analysis of elements to be considered in public

health alignment within the LHIN mandate -- found in ECCO 2.043

and in submission on Bill 41: Patients First Act, 201644

be referenced

on this.


OPHS Document RNAO Feedback, Questions, and Recommendations Global movement to advance health equity as discussed above should

be included as a driver. Truth and Reconciliation Commission45

and

Ontario's The Journey Together: Ontario's Commitment to

Reconciliation with Indigenous Peoples46

should also be listed as

triggers for transformative change.

Boards of health delegate

authority for the day-to-day

management and administrative

tasks to the Medical Officer of

Health (MOH) (and CEO or

other executive officers) p. 7

The roles, functions, and competencies of Medical Officers of Health

and Chief Executive Officer are distinctly different. Given the

necessary content expertise and the heavy demands of these two

distinct roles (MOH and CEO), RNAO urges in the strongest possible

way, to separate the role of MOH and that of CEO. Indeed, this is the

case in all other sectors. The role of CEO should be open to any

health professional that meets the necessary requirement of

management and administrative oversight.

Partnership, collaboration and

engagement, including with

"priority populations" p. 10

An identified concern with the term "priority populations" is that

"without specific inclusion of social justice values, the term can be

interpreted too broadly, and be used to identify populations not

experiencing disadvantages."47

High risk, vulnerable, marginalized,

and equity-seeking groups are among the many terms often used but

every label needs unpacking in each context to address power

dynamics influenced by language.48

Consistent with the health equity evidence, care must also be taken to

focus on the broader conditions that create inequities rather than the

groups. "For example, 'the homeless' may be viewed as a group of

people without housing in need of individual-level intervention, as

opposed to recognizing the effect of structural conditions that affect

homelessness such as an inadequate supply of affordable housing or

the history of colonization. We need to think about 'what are the

structural conditions in which vulnerabilities are created?,' instead of

only the groups we see being affected and at risk."49

Resources for unpacking and operationalizing these concepts may be

found at websites linked to the World Health Organization,50

and the

National Collaborating Centres funded by the Public Health Agency

of Canada, including the National Collaborating Centre for

Determinants of Health,51

National Collaborating Centre for Healthy

Public Policy,52

and the National Collaborating Centre for Aboriginal

Health.53

Population Health Assessment

Foundational Standard,

p. 12-13

The technical briefing noted the removal of the Nutritious Food

Basket Protocol from the 2008 OPHS version under Chronic Disease

Prevention. This MOHLTC briefing said "collecting data on the cost

of a nutritious food basket remains in the Population Health

Assessment and Surveillance Protocol."54

RNAO affirms how critical the data from the Nutritious Food Basket

Protocol is to research on health and social policy related to the social

determinants of health inequities. This protocol is a structure-based

intervention55

as well as a tool that compares income levels for people

receiving social assistance or minimum wage with the actual cost of


OPHS Document RNAO Feedback, Questions, and Recommendations food and shelter. It is imperative that this information still be

collected across the province and be readily available to help track

progress on the province's poverty reduction plan.

Ensure that priority populations/ equity-seeking groups/ people with

lived experience of being marginalized are consulted and engaged in

a meaningful way as part of the population health assessment. It

would be helpful to provide guidance and share best practices on

respectful, inclusive processes, including the need for adequate time

and resources to build authentic relationships.

Health Equity Foundational

Standard, p. 15-16

The stronger mandate to engage, build, and/or develop relationships

with Indigenous communities and organizations is essential and fills a

foundational gap.

The goal of this standard is consistent with the WHO conceptual

frameworks. "Public health practice aims to decrease health inequities

such that everyone has equal opportunities for health and can attain

their full health potential without disadvantage due to social position

or other socially determined circumstances." This framing better

serves the overarching goal of reducing health inequities compared

with the downstream objective of "reducing the negative impact of

social determinants of health that contribute to health inequities" p. 5.

Suggest revising second bullet on p. 16 to read: "Community partners

and the public are aware and engaged in local strategies to address

health inequities and their causes through policy development and

policy advocacy."

Suggest revising number 4, requirements, on p. 16 to read: "The

board of health shall lead, support, and participate with other

stakeholders in policy development, policy advocacy, health equity

analysis, and promoting decreases in health inequities."

Advocacy is not mentioned in the OPHS although it is "a critical

population health strategy that emphasizes collective action to effect

systemic change."56

Advocacy is a critical means of improving health

equity5758

and is a core competency of public health professionals.59

Effective Public Health Practice

Foundational Standard, 17-18

Concerns were raised about continuity of services and continuity of

care for vulnerable clients who might fall through the cracks during

system transformation. Please see discussion on sexual health clinical

services and harm reduction services. Evidence-informed decision-

making when starting, stopping, and changing programs and policies

will require utilization of tools such as the Health Equity Impact

Assessment60

informed by collaborating with equity-seeking groups.

Chronic Diseases and Injury

Prevention, Wellness and

Substance Misuse Standard,

22-24

There is a concern that a lack of overall minimum standards in the

effort to allow for increased flexibility may allow for too much

interpretation and so increase variability among health units. The

Children Count report61

identified a need for a more coordinated and

consistent surveillance approach across the province. The risk is that


OPHS Document RNAO Feedback, Questions, and Recommendations current gaps in surveillance data will worsen and the province will

lack comparable health status information.

Consistent with clearly described public health roles and evidence-

based interventions, more language is needed on comprehensive

health promotion strategies (capacity building, supportive

environments, skill development, policy development) as was in the

previous standards.

Cannabis is not specifically named as a requirement. In the context of

pending legalization, this is an important public health issue. There is

a need for a provincial strategy on cannabis and youth.

There is a need for a public health evidence-informed provincial

alcohol strategy.62

Healthy Environments Program

Standard, 27-28

RNAO commends the expansion of the goal of this standard to

include the promotion of "the development of healthy natural and

built environments that support health and mitigate existing and

emerging risks, including the impacts of a changing climate."

Consistent with RNAO's ongoing health equity feedback, it is also

critical to address environmental challenges such as climate change,

extreme weather, pollution, etc. through context specific strategies

that tackle both structural and intermediary elements as shown in the

Appendix. Structural determinants of health inequities lead to

stratification with differential exposure, vulnerabilities, and

consequences for disadvantaged groups.

Public health units should be developing healthy public policy and

developing community partnerships to support mitigation,

preparedness, and building resiliency within municipal governments

and in the community related to extreme weather, especially for

marginalized and vulnerable populations. The Chicago heat wave of

1995 with its high mortality of racialized people living in poverty and

isolation is a cautionary case study to illustrate this argument.63

Healthy Growth and

Development Program Standard,

29-30.

As population health encompasses populations from preconception to

death, RNAO recommends changing the title and focus of this

standard to "Healthy Growth, Development and Aging." The draft

OPHS do not mention "seniors" or "aging." Considering the growth

of this demographic in our population64

and the intention that public

health play a role in health system planning, this is a serious

omission.

Where in the standards will the needs of children and youth who are

not in school be addressed?

Missing elements include:

Baby-Friendly Initiative (BFI)

direction to increase rates of breastfeeding to six months


OPHS Document RNAO Feedback, Questions, and Recommendations

nutrition, including food insecurity

sleep

A protocol for post-partum depression screening is required.

Infectious and Communicable

Diseases Prevention and Control

Program Standard, p. 36

RNAO is concerned about the implications for clients and the

community of replacing language around "provision" to "promoting

access" to sexual health clinical services, and harm reduction

programs and services.

Sexual health clinical services: Continued access to specialized STI

testing and treatment, low cost contraception, and Pap testing for

populations at risk is a crucial service. A review of sexual health

clinical services in Toronto indicated that current providers, such as

community health centres, do not have the capacity to provide this

service to more clients. Additionally, this change could limit access to

confidential services for youth and stigmatized populations that do

not feel comfortable accessing their health care provider. It would

also compromise access for people without a health care provider,

including people without OHIP.

Harm reduction programs and services: RNAO is deeply

concerned that this change seems to be a weakening of public health's

role in harm reduction and the importance of these services. This is

alarming in light of recent opioid overdoses and deaths across the

province65

and the need for increased harm reduction including

supervised injection services.66

School Health Program

Standard, p. 42-43

Consistent with the evidence on the contribution of public health

nursing in school settings to improve health,67

68

69

RNAO applauds

the new School Health Program Standard. Public health nurses are

ideally situated to make a difference in the lives of children, families,

and school communities by providing direct services, and engaging in

health promotion, and disease prevention. RNAO looks forward to

working with the MOHLTC on operational issues related to moving

this important opportunity forward.

Additional areas of health promotion we identified include:

cancer prevention

diabetes prevention

injury prevention

supporting newcomers

supporting children and youth through the education system

As older adolescents continue to need public health nursing support

while they individuate from their families in the sometimes unfamiliar

new surroundings of a college or university, RNAO recommend that

this School Health Standard include post-secondary students.

Vision screening is included but there is conflicting evidence about

the effectiveness of this type of program. It is difficult to get buy-in


OPHS Document RNAO Feedback, Questions, and Recommendations when the evidence is weak. More specific information about what

interventions are expected and a protocol will be required before

being able to assess the implications for health units. RNAO

recommends that vision screening be integrated into the other public

health screening programs in consultation with the Ministry of

Children and Youth Services and a similar model be applied.

This comment crosses both the Immunization and School Health

standards. Greater clarification is required about expectations related

to children in schools, school-aged children and working with

schools, and the rationale for including immunization in the School

Health Standard.

For all program standards

Some health units may not view foundational standards as needing to

be met by individual programs so long as they are met by centralized

support services. As a result, RNAO recommends that all program

standards include outcomes related to social determinants of health

and social determinants of health inequities. As written now, program

outcomes have a lifestyle and behavioural focus that does not advance

the goal of improving health equity. All programs need to engage in

meaningful ways with those with lived experience/priority

populations/equity-seeking groups to help inform work. Policy

advocacy and policy development should be built into all program

standards as upstream interventions to impact health equity.

Implementation considerations

Time and resources are required to build capacity to implement the

standards utilizing best practices in leadership and change

management. This could involve:

restructuring within public health units?

development and implementation of new policies and

procedures?

changing of staff roles? hiring? labour relations?

education and training, including cultural safety, cultural

sensitivity, meaningful engagement with people with lived

experience?

prevention of unintended impacts such as possible re-

allocation of health unit resources to centralized, internal

positions thereby impacting staff ability to work directly with

priority populations on health inequities?

access to data and analysis support for health units where

capacity is limited?

Thank you for considering this feedback in support of the critical goal of improving population health and decreasing health inequities. Please do not hesitate to be in touch if additional information would be helpful.


Appendix 1 Frameworks from the Commission on the Social Determinants of Health

Solar & Irwin (2010).A Conceptual Framework for Action on the Social Determinants of health. Social Determinants of Health Discussion Paper 2, Geneva: World Health Organization, 6.


Solar & Irwin (2010).A Conceptual Framework for Action on the Social Determinants of health. Social Determinants of Health Discussion Paper 2, Geneva: World Health Organization, 60.


Priority public health conditions analytical framework

Blas, E. & Kurup, A. (eds). (2010). Equity, social determinants and public health programmes. Geneva: World

Health Organization, 7.


Blas, E. &Kurup, A. (eds). (2010). Equity, social determinants and public health programmes. Geneva: World

Health Organization, 13.


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Registered Nurses’ Association of Ontario (RNAO)

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